Provider Demographics
NPI:1972898013
Name:ROBERT J CASEY DO PC
Entity type:Organization
Organization Name:ROBERT J CASEY DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:CASEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:928-532-1220
Mailing Address - Street 1:PO BOX 2930
Mailing Address - Street 2:
Mailing Address - City:PINETOP
Mailing Address - State:AZ
Mailing Address - Zip Code:85935-2930
Mailing Address - Country:US
Mailing Address - Phone:928-532-1220
Mailing Address - Fax:928-532-1222
Practice Address - Street 1:5171 CUB LAKE RD STE 270
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7888
Practice Address - Country:US
Practice Address - Phone:928-532-1220
Practice Address - Fax:928-532-1222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-16
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1955207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ239683Medicaid